Wednesday, May 02, 2012

Blame the DSM?

About a year ago, a young mother called me, extremely distressed. She
had become seriously sleep-deprived while working full-time and caring
for her dying grandmother every night. When a crisis at her son’s
day-care center forced her to scramble to find a new child-care
arrangement, her heart started racing, prompting her to go to the
emergency room.

After a quick assessment, the intake doctor declared that she
had bipolar disorder, committed her to a psychiatric ward and started
her on dangerous psychiatric medication. From my conversations with this
woman, I’d say she was responding to severe exhaustion and alarm, not
suffering from mental illness.

Caplan goes on to express her concerns with psychiatric diagnoses, the DSM, the problems with these labels that lead to the use of dangerous medications. Oh, we've been here on Shrink Rap before, see "Diagnostic Labels That Change Lives".

Caplan continues

In our increasingly psychiatrized world, the first course is often to
classify anything but routine happiness as a mental disorder, assume it
is based on a broken brain or a chemical imbalance, and prescribe drugs
or hospitalization; even electroshock is still performed.

According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders
(DSM), which defines the criteria for doling out psychiatric labels, a
patient can fall into a bipolar category after having just one “manic”
episode lasting a week or less. Given what this patient was dealing
with, it is not surprising that she was talking quickly, had racing
thoughts, was easily distracted and was intensely focused on certain
goals (i.e. caring for her family) — thus meeting the requisite four of
the eight criteria for a bipolar diagnosis.When a social worker
in the psychiatric ward advised the patient to go on permanent
disability, concluding that her bipolar disorder would make it too hard
to work, the patient did as the expert suggested. She also took a
neuroleptic drug, Seroquel, that the doctor said would fix her mental
illness.

Caplan goes on to say that because of the existence of a psychiatric label-- one she contends is wrong-- the patient lost her friends, her marriage, her home, her self-confidence, her wealth, was forced to move across the country to somewhere she was isolated, and the six weeks she spent on medication (presumably Seroquel) left her with a condition that may someday leave her blind.

Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully
to understand their suffering — and help them find more natural ways of
healing. Exercise, good nutrition, meditation and human connection are
often more effective — and less risky — than drugs or electroshock.

Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk." -------------Where do I even begin? Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot Psychiatrist Theme with a sensationalist tone. Shame on the Washington Post for printing this.

Okay, so I couldn't quite follow the case she presented, at first it sounds like the patient went to the ER with symptoms of a cardiac problem, or exhaustion, or a maybe a panic attack. Perhaps, but some imbecile ER doc did a check list of symptoms, told her she had Bipolar disorder, and without even listening to her, weighing other options, or taking into consideration the context of her life, sent her off with Seroquel and a recommendation for therapy. This misdiagnosis then destroyed her life, because why would her husband and friends stick with her if she's got bipolar disorder? What better time to leave your wife then when her grandmother is dying, she's stressed out and sick? So she went to the ER because she was tired and her heart was racing. I think they see this all the time...I think they do an EKG and perhaps make sure the patient isn't having a heart attack or arrhythmia, and if they think it's anxiety, the patient gets a dose of a benzodiazepine, and gets sent home. Okay, but it's an ER and the docs are rushed and focused on what the patient needs now. They make wrong diagnoses all the time, and it's not just psychiatry, and it's not just because the doctor is sitting there with the DSM or has memorized the hundreds of possible diagnostic criteria.

Okay, but it turns out that she was on a psychiatric ward. You can't get admitted to a psychiatric ward because you're tired, with racing thoughts, a fast heartbeat, talking fast and being distracted. Pretty much, you need to be a danger--, suicidal, or having severe hallucinations or delusions, or be in extreme distress in some way. This was a wealthy patient who could afford outpatient care. All I'm sure of, is there is something more to the story.

Finally, the patient was admitted to a psychiatry unit, so presumably there was a second doctor who met with the patient and a treatment team that observed her behavior for a few days. Okay, I've stories of really lousy inpatient care, and I do believe the diagnosis could still be wrong and the treatment that was recommended might be wrong, or helpful at the moment but not necessary for the long-term, but I don't buy that a misdiagnosis let to the complete demise of this patient's life and a need to move across the country. These are the types of problems one sees as a result of the behaviors a person might have because they have a mental illness, perhaps one such as bipolar disorder.

So I don't know the patient, or the diagnosis. But I do know that the entire premise for this article is based on the idea that the patient was simply tired and stressed and perfectly normal and did not have a psychiatric disorder (the author tells us this) and this label alone destroyed her life. The reader is not allowed to even entertain the idea that the patient had a psychiatric disorder-- that maybe the psychiatrist did get some history and make reasonable observations, and the patient really did have bipolar disorder? (Obviously, I don't know this). There's no mention of a review of the records, discussion with family, interview of the doctor, Caplan is telling us her impression based on the patient's report only. Maybe the patient had panic disorder, or a personality disorder, or even an adjustment disorder (perfectly possible given the stresses involved). Oh, but then she took a bum recommendation to go on disability, and she
got it! I've seen really sick people not get disability. It takes a
lot of documentation and the government looks for ways to avoid paying
this-- you don't get disability for having a psychiatric diagnosis, you have to be disabled by it. So, somehow, this patient who was simply exhausted and
stressed, with No Psychiatric Disorder, per Dr. Caplan, managed to get
admitted to a hospital and get disability benefits.

There were some valid points Caplan could have made. The DSM is not a 'scientific manual.' Personally, I don't find it terribly helpful in clinical practice. I don't keep a copy in my office (I bought one to use while writing Shrink Rap), and I'm not planning to buy the DSM-V. The overall concept is good, and it's very helpful to researchers to be certain that the groups they study have some diagnostic reliability, otherwise there is no way if knowing if a certain treatment addresses a specific group of people who can reliably be classified as having a specific illness. This isn't all bad, but I don't need 370-400 diagnosis for my work (predicted in the new DSM-V). And Caplan makes the statement that the editor, Allen Frances, says the work is based in science but has spread it's net too far. If you readDr. Frances' blog, you'll note that he is quite skeptical and opposed to many of the proposed changes for DSM-V. It's not like the psychiatrists aren't thinking hard about these diagnostic categories and the ramifications they have. Still, I'm skeptical about how we think about these disorders, especially Bipolar Disorder.

I agree with Caplan that psychiatrists should listen more. Fifteen-minute med checks have made a mockery of our profession. I also tell all of my patients to exercise, eat healthy, and look for ways to solve their problems. But to imply that these things are the answers for the majority of people who are suffering (and often too distressed, depressed, and unmotivated, to just pull up their bootstraps, get up and exercise and cook a healthy meal )-- is an insult. You know, sometimes those things really do work, but if people are able to do those things, they've often tried them before seeking psychiatric opinions. To read Caplan's piece, you'd think everyone is an idiot. And finally, ECT: it still in use because some people find it helps.

19 comments:

Well said. I tried to read Caplan's book - had to put it down secondary to an odd combination of boredom and irritation. I think she suffers from the blindness often experienced by Crusaders - she's decided that psychiatry is bad, patients are victims and well, she just needs to tell EVERYBODY (for the low low price of 14.95 each.)

Fantastic post Dinah - lots of food for thought and a balanced discussion on a very thorny issue. I'd not consider that a rant in any way! Yes, we do sometimes get it wrong but like you, I smell a bit of a rat here. And getting it wrong in the other direction, where people don't ask for help that they do need because they've read stuff like this tosh in the media, can be just as and often more devastating. I wonder if the authors of such articles think about such things when they put pen to paper.

I also tried and failed to read Caplan's book. She seemed to want to make a larger argument about the failures of the DSM, in her book, but she got so wound up about PMDD in particular that it turned into a rant. I have a hard time figuring out how to react to her. She has some good points, but they turn into laughable rants like this; she's fighting some of the same mainstream psychiatry stuff I fight, but she does it so poorly that I guess I am kind of embarrassed to have her on my side.

Reading Paula Caplan's article and also your rebuttal, I agree a lot more with Paula Caplan's perspective than yours, based on my experience as a "consumer" of mental health services. My personal experience supports what Paula Caplan says.

Diagnoses are given quickly. Patients are pressured to "accept" their diagnosis. Patients are told they have to stay on medications for life. I was repeatedly pressured to give up my business, which I had run successfully for 25 years. I did quit the business, then several months later tried to restart it, but having told everyone I had closed I was unable to get it off the ground again so I was forced to change occupations which meant going back to school in my late 50's. The psychologist I saw refused to talk about any of the problems I was dealing with and spent her time getting me to accept I am mentally ill and need to be on medications forever. (Note: my current psychiatrist urged me to go off medications in early 2006 after 8 months on it, and he was not wrong. He is the exception to the system, not the standard. He has been practicing psychiatry for over 40 years and does not believe everyone needs medications. I am able to lead a full life without medication that was robbed from me on medications due to loss of cognitive ability on medication.)

The fact that the patient was wealthy does not mean the hospital would send the patient to be cared for as an out-patient. Hospitals like patients who have good insurance and lots of money to pay the difference between the insurance reimbursement and full price.

The final tossed in comment at the end about ECT made my blood boil. I wonder what percentage of depressed psychiatrists volunteer to have ECT themselves. A link you formerly posted to Dr. Shock's website, led to a story about "successful" treatment of a teen girl with ECT. There was a link to the girl's blog. I watched her full series of posted video diaries and it was shocking to see her memory and cognitive functions deteriorate on screen. The girl had been in community college and became unable to read or remember things after ECT, and she still couldn't read a year after ECT. A NYTimes writer wrote an article in NYTimes after ECT that said he effectively had lost his occupation due to ECT because he lost vocabulary and the ability to write. ECT is involuntarily administered in many states including California where I live. I hope one day this barbaric practice ends.

While those in the profession may fell the practice of psychiatry is perfect as is, articles such as this, which express the opinion of many people in the patient population, ought to be a hint that all is not well in the mental health profession. When I was in business, there was a saying that I found to be very true. It was: "The customers who complain benefit all those who never say anything because it allows you to improve areas of weakness in the business." If instead of assuming that the psychiatry profession is perfect, the profession would listen to the (loud!) complaints of patients, then the treatment of the mentally ill might advance.

Caplan was actually a member of previous DSM committees until she resigned over what she saw. Anyone who wants can read more on her perspective: http://www.awpsych.org/index.php?option=com_content&view=article&id=101&catid=74&Itemid=126

Dinah is like many doctors in agreeing the DSM is of little value. Caplan stands behind patients in pointing out the very real dangers of the DSM. It doesn't matter as much that you do not like the example she chose to use in her article. I do believe it could happen. I was diagnosed in 30 minutes, and I was not in a crisis at the time. I told by another doctor that they would be willing to testify that I was a good parent if my spouse chose to divorce me over the fact that I was now classified as a mentally ill (defective) person/bad parent. I didn't ask. There was obviously some expectation on the doctor's part that this might occur.I am going through a very difficult time in my life right now. The doctor's immediate response is: "let's give you more medications." I asked whether the doctor would place himself on those meds if he was having the same difficult time, for the same reasons.He withdrew his declaration. Having a diagnosis makes it very easy for people to dismiss all your emotions and actions or reactions as sick even when they would be considered normal for someone without a diagnosis. And to Sunny, your comment was excellent.

I don't like it when patients are pushed into inappropriate treatments. Inappropriate in any way: not chosen by the patient through informed consent, not applicable to the patient, without enough consideration of the side effects and alternatives, etc. But. I am very wary of counting almost any treatment out. Mental illness can be so so awful and I don't want to preclude someone from relief by disallowing a treatment that could be their way out. At the very least, I want to leave that option open to the patient (not so much to the doctor, except for the ability to inform the patient). It is hard for me to reconcile treatments that seem clearly abusive (lobotomy, wetpacking, etc.) with my terror at anyone not having a treatment available to them that could give them some measure of relief from their mental illness.

You are right that we don't have the whole story...but it could happen. When Shtink2Be had Sizing Up the Shrink, he wrote about a patient he interviewed (could've been confabulated...who knows). The patient told him that she did not feel she needed to be inpatient. She had been made inpatient because she told a psych nurse that she had had a plan to commit suicide. That seemed like a pretty good reason to shrink2be...until she told him that the plan was five years ago, when her husband was really sick, and she thought about killing herself. She didn't even show up trying to get hospitalized to the psych unit. She was just looking for some counseling. Shrink2Be apologized and took this as a lesson to always ask about the timeline of symptoms.

You could probably take any symptom out of context if asked in a specific way. This goes for any healthcare professional--not just mental health professionals. And I know for a fact that they very rarely interview children. They usually just interview the parents and go off of whatever they reported. It might be better since I was young, but it was pretty rare for them to interview minors. They could pretty much do whatever they wanted with you so long as it came out of the mouth of an adult. Make you inpatient, medicate you, whatever.

Here is something REALLY freaky. When I was 18 years old, I made an appointment with a psychiatrist. It was out of my own pocket. I had my dad give me a ride. When I went in to see her, I said "Bye Dad" or whatever I said. I was horrified when she made him stop and said, "I'd like to speak with him too." I didn't stop her, because I really thought that she would maybe speak to him for five minutes and spend the rest of the time with me. She literally spent the vast majority of the time talking to him. I was in total shock, because I was 18 and I thought by that age I would be the one who was primarily interviewed. All of her questions that she addressed to me were in the presence of my father and she allowed him to interrupt me while he provided totally inaccurate information. He took everything out of context. When she concluded with us, I said, "But you didn't even really talk to me! You just asked him questions!" She then replied, "I spent equal amounts of time talking to you both." And she really believed that. I didn't go back.

Ever since that happened, I have NEVER brought a family member with me. And I never will again. The fact that she thought, out of the 45 minute interview (whatever it was), that he deserved even HALF the time was too much for me to mentally digest. If I'm paying, the majority of the interview is conducted with me.

Psychiatry, as it is practiced now- mostly medication based, is a scam.

Consider this, which was published in the New England Journal of Medicine, 4 YEARS AGO!!!

http://www.nejm.org/doi/full/10.1056/NEJMsa065779

"Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy"

"We found a bias toward the publication of positive results. Not only were positive results more likely to be published, but studies that were not positive, in our opinion, were often published in a way that conveyed a positive outcome. We analyzed these data in terms of the proportion of positive studies and in terms of the effect size associated with drug treatment. Using both approaches, we found that the efficacy of this drug class is less than would be gleaned from an examination of the published literature alone. According to the published literature, the results of nearly all of the trials of antidepressants were positive. In contrast, FDA analysis of the trial data showed that roughly half of the trials had positive results. The statistical significance of a study's results was strongly associated with whether and how they were reported, and the association was independent of sample size. The study outcome also affected the chances that the data from a participant would be published. As a result of selective reporting, the published literature conveyed an effect size nearly one third larger than the effect size derived from the FDA data."

"Selective reporting deprives researchers of the accurate data they need to estimate effect size realistically. Inflated effect sizes lead to underestimates of the sample size required to achieve statistical significance. Underpowered studies - and selectively reported studies in general - waste resources and the contributions of investigators and study participants, and they hinder the advancement of medical knowledge. By altering the apparent risk-benefit ratio of drugs, selective publication can lead doctors to make inappropriate prescribing decisions that may not be in the best interest of their patients and, thus, the public health."

This is http://en.wikipedia.org/wiki/The_New_England_Journal_of_Medicine .It has the interests of medicine at large, not just psychiatry's, in mind.They fell short in calling things involving trials of psychotropic drugs for what they are: fraud, scam. Such selective publishing would have been considered scientific misconduct in hard science fields and other areas of medicine.

This was published in January of 2008. Most financial conflicts of interests by the American Psychiatry Association, NAMI and people like Biederman, Keller, Nemeroff and Schatzberg as a result of the work by US Senator Chuck Grassley were exposed later that year. In 2009, the manyfacturer of Prozac and antipsychotic Zyprexa, was forced to pay 1.4 billion dollars in a settlement for off label marketing of Zyprexa. Since Eli Lilly has made around 40 billion dollars on revenue from Zyprexa, they are fine with paying such significant fine.

I has taken 4 years for the mainstream media to take notice of this. Psychiatry is in need of an overhaul. Efforts such as Paula Caplan's are to be applauded.

I realize you prefaced this with a note you were intending to be sarcastic but....It's hard to take you seriously as a professional when you write something like this, and not just because I don't agree with all that you are defending. The immaturity, one-sidedness, adn implied self-aggrandization is hard to take.

Family member of people with psych things, person with psych things, peer support, and now clinician.

The problems we see are systemic. Psychiatrists take a lot of flack, but it is not just them. It's federal and state governments, it's societal stigma, it's managed care, it's corporations (pharmaceutical and arguably alt/com - they're an really large industry and certainly make a buck off of psychotropic things), it's private mental health entities, it's public mental health, it's advocacy groups, it's clients, it's schools, it's all other physician specialities, and sorry Dr. Caplan, it's therapists, too. We all contribute to the system, good and bad, and the system is symptomatic.

The founders of mental health theories did not promote how we actually treat mental health. Emil Kraeplin did not suggest people eschew personal responsibility just because something is heritable. Dorthea Dix fueled the Moral Treatment Movement so that people with psychiatric diagnoses weren't locked away in attics, homeless, or in jail. Freud seemed pretty convinced that everyone is screwed up to some degree, and there aren't too many special snowflake normal people out there. Moreno, founder of psychodrama, felt all people could experience catharsis. Carl Rogers's person-centered therapy stresses unconditional positive regard. And psychiatric drugs, as much as we demonize them, were a catalyst in getting people back into the community.

Everyone, professional or not, needs to start challenging how things are done. Some folks are. One thing to keep in mind, though, is that brains are physical entities. Behaviors, senses, emotions, energy levels, etc. that are impairing are a problem with the brain. The brain does not have a magical barrier that keeps it from becoming ill. I am not saying that everyone needs medication - I am saying that continuing to treat psych issues like the source is some nebulous phenomenon is not doing anyone any favors. It leads to blame. And clients aren't aways innocent - I say this as someone who spent a few years in denial, later lying about things that hampered my treatment when I finally sucked it up and made the call.

As for ECT, I have met a few people who have had it done. One person loved it so much she doesn't take medication and goes in for ECT for a "tune up" as needed. I've also met someone who lost a few years worth of memories (though she was shortly diagnosed with dementia afterwards - she did have all of the symptoms, and her memory was declining quickly though ECT was discontinued a decade prior - so no telling). The typical story is it's a last ditch effort, it works, there's memory loss surrounding the sessions, and overall it's not a horrible experience. I personally think that there are entirely too many treatment options to make ECT something that can be court-ordered. If it's voluntary, why not.

Psychosurgery also still exists, though its rare. I believe its used in incredibly extreme cases of OCD. Having been down the OCD road, I can honestly see where someone might consider this an option. It's painful to live with when it rears its ugly head - about as much as depression, honestly; more so for me.

I actually have quite the social justice bent - voting, writing state legislatures, speaking out whenever possible, so forth. We definitely need to stress choice, education for clients and providers, the humanity of clients, family, and providers, alternatives to seclusion and restraint (now that I have a major problem with), working with children and teens towards recovery (Recovery Movement doesn't mention them all that much), and probably a bunch of other things.